JOURNAL OF ORAL & MAXILLOFACIAL RESEARCH Silveira et al.

Accidental Displacement of Third Molar into the Sublingual

Space: a Case Report

Rubens Jorge Silveira1, Robson Rodrigues Garcia1, Tessa Lucena Botelho2, Ademir Franco3,
Rhonan Ferreira Silva4,5
1
Department of Maxillofacial Surgery, Paulista University, Brazil.
2
Department of Radiology, Paulista University, Brazil.
3
Department of Stomatology, School of Health and Biosciences, Pontifcia Universidade Catlica do Paran, Brazil.
4
Department of Legal Odontology, Federal University of Goias, Brazil.
5
Department of Legal Odontology, Paulista University, Brazil.

Corresponding Author:
Rubens Jorge Silveira
74845-090, Rodovia BR-153, Km 503 - Fazenda Botafogo
Goiania, Goias
Brazil
Phone: 00 55 62 32394000
Email: rubensjs30@hotmail.com.br

ABSTRACT

Background: Successful extraction of third molars depends on preoperative diagnosis and planning. Gold standard
preoperative examinations are performed through computed tomography, decreasing risks and avoiding potential accidents.
The present report highlights the value of preoperative examinations in face of accidentally displaced third molars.
Methods: An 18-years-old female patient underwent a third mandibular molar extraction with a general dentist. Accidentally,
the mandibular left third molar was displaced into the sublingual space, making necessary a second surgical step. The surgery
was interrupted and the patient was referred to an expert in maxillofacial surgery.
Results: After 21 days awaiting an asymptomatic health status, the second surgical step was successfully performed using
multislice computed tomography as preoperative imaging guide.
Conclusions: The present case report highlights the clinical usefulness of imaging planning and informed consents in face of
legal and ethic potential complaints.

Keywords: third molar; multislice computed tomography; oral surgery; tooth extraction.

Accepted for publication: 29 August 2014

To cite this article:
Silveira RJ, Garcia RR, Botelho TL, Franco A, Silva RF. Accidental Displacement of Third Molar into the Sublingual Space:
a Case Report.
J Oral Maxillofac Res 2014;5(3):e5
URL: http://www.ejomr.org/JOMR/archives/2014/3/e5/v5n3e5ht.pdf
doi: 10.5037/jomr.2014.5305

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JOURNAL OF ORAL & MAXILLOFACIAL RESEARCH
INTRODUCTION
In general, the third molar extraction is considered
a procedure of minor proportion into the field of
maxillofacial surgery. However, this procedure
requires a specific surgical indication, planning,
technical approach, and follow-up.
Transoperative accidents related to the extraction
of third molars often involve fracture of the
adjacent bone and teeth, laceration of soft tissue,
haemorrhage, neural lesions, and dental displacement
into the maxillary sinuses, extracranial fossae,
and cervicofacial spaces [1]. Specifically in the
medical literature, mandibular third molars were
reported displaced into the infratemporal fossa [2];
the pterygomandibular fossa [3]; and the lateral
pharyngeal [4], submandibular [5,6] and sublingual
[7] spaces. In this context, the sublingual area is
a triangular virtual space, located in the floor of
the mouth, above the mylohyoid muscle, under
the free portion of the tongue. The lateral limit
of the sublingual space is the muscle complex
hyoglossus-styloglossus, while the anterior limit is
the genioglossus muscle [8]. Important morphologic
structures are observed in the sublingual space, such
as the duct of the submandibular salivary gland,
branches of the lingual artery, and the lingual and
hypoglossal neural bundles [7]. Thus, third molar
extractions should be preferentially performed by
maxillofacial surgeons, who are highly familiarized
with the surgical morphology of head and neck.
In addition, preoperative imaging must be properly
used to avoid potential accidents in the routine of
dental surgery. Based on that, the present study reports
a case of a transoperative complication, in which a
mandibular third molar was accidentally displaced
into the sublingual space.
A B
Figure 1. Superior (A) and inferior (B) views of the mandible, presented in three-dimensional reconstruction by means of multislice
computed tomography, illustrating the position of the tooth #38 (indicated by the arrows).
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Silveira et al.
CASE DESCRIPTION AND RESULTS
In December, 2012, an 18-year-old female patient
underwent extraction of the mandibular left
third molar (tooth #38) for orthodontic reasons.
Accidentally, the tooth #38 was displaced from
the dental socket to an unknown adjacent site. The
surgery was interrupted after the patient complains
about the prolonged time taken to find the tooth.
Anti-inflammatory (Ibuprofen 600 mg) on every 12
hours, and analgesic (Metamizole Sodium 500 mg)
on every 6 hours, were prescribed covering a period
of 3 days after the surgery. The patient was referred
to a radiology clinic for a proper diagnosis by means
of multislice computed tomography, using a Toshiba
Aquilion 64-channels (Toshiba Corporation, Tokyo,
Japan) device.
Three-dimensional reconstructions and axial and
coronal slices enabled to detect the third molar in
the medial surface of the left mandibular ramus in
an inverted position (Figures 1 and 2). In addition, a
detailed examination revealed that the third molar was
displaced above the mylohyoid muscle, laterally to the
tongue: into the sublingual space (Figure 3).
Despite advised about the importance of a
second surgical intervention, the patient became
apprehensive and uneasy in the following days.
Additionally, functional and psychological
conditions were worsened due to the presence of
trismus, hampering daily activities. Based on that,
the patient was convinced to undergo a second
surgery only after 21 days from the accident. The
second surgery was performed by an expert in
the field of maxillofacial surgery. The surgical
costs were afforded by the first dentist. During
the preoperative examination the patient physical
status was classified as ASA I, enabling the surgery.
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A B

Figure 2. Axial (A) and coronal (B) views of the mandible, presented in two-dimensional slices for bone analysis by means of multislice
computed tomography, revealing a small bone fragment of the left lingual cortical plate (indicated by the arrow), broken during the surgery.

A B

Figure 3. Coronal (A) and sagittal (B) views of the mandible, presented in two-dimensional slices for soft tissue analysis by means of
multislice computed tomography, illustrating the relation between the tooth #38 (indicated by the arrows) and the morphologic limits of the
sublingual space.

Based on that, the patient was medicated with 8 mg
of orally administered corticosteroid dexamethasone
1 hour prior to the surgery, aiming optimal
postoperative outcomes. The second surgical
procedure was performed under mandibular nerve
block, using Lidocaine 2% with adrenaline 1:100.000
(Nova DFL, Rio de Janeiro, Brazil). The third molar
was accessed and successfully removed through
an envelope incision, with a mucoperiosteal flap
detachment from the retromolar trigone to the medial
surface of the mandibular left first molar (tooth #36).
In the following week the patient received the same
medication prescribed in the first surgical attempt.
Despite the close relation between the tooth #38 and
the submandibular salivary gland and the lingual
nerve, the patient did not report postoperative sequels
within a follow-up period of 45 days.
DISCUSSION
Displacement represents one of the most important
accidents during the extraction of third molar due
to the common need for major secondary surgical
steps [2-6]. Additionally, accidentally displaced
third molars may cause iatrogenic/traumatic neural
injuries [9] and even temporomandibular joint pain
and dysfunction [10]. The current literature reports
the displacement of both maxillary and mandibular
third molars. Specifically, Gomz-Oliveira et
al. [11] described a case in which a maxillary
third molar was displaced into the infratemporal
fossa. Despite the close relation with the internal
maxillary artery and the venous pterygoid plexus,
the third molar was removed through a secondary
surgical intervention, performed 2 weeks after the
initial attempt, under local anesthesia. Similarly,
Hoekema et al. [12] reported the accidental
dental displacement into the same anatomic site.
However, the authors state that asymptomatic
patients could be treated with periodic clinical and
radiographic follow-ups prior to additional invasive
approaches.

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Yet in extractions of mandibular third molars, most
of the accidents involve the displacement of dental
roots. It is justified due to the tilted position in which
mandibular third molars are often observed, which
makes necessary the crown resection prior to the
dental extraction [13]. Huang et al. [14] reported a
case in which a third molar root was displaced into the
pterygomandibular space. In this situation, the patient
was successfully reoperated 5 months after the initial
attempt, under general anesthesia and intraoral access.
Similarly, Aznar-Arasa et al. [14] compiled 6 cases
of third molar root displacement into the sublingual
space. Specifically, the authors observed that 2 out
of the 6 cases required a secondary intraoral surgical
intervention for root retrieval. Both of the patients
presented postoperative impairment of the inferior
alveolar and lingual nerves. The other 4 patients
were asymptomatic, excluding the need for a new
surgery. Differently, in the present report an entire
third molar was displaced into the sublingual space,
indicating that the tooth was in a favourable position
for extraction, in which the crown resection was not
necessary. Besides, wrong surgical techniques are
closely related to the transoperative displacement of
third molars [15], potentially justifying the accident
reported in our study. The same was observed in the
reports of Pippi and Perfetti [16], and Olusanya et
al. [17], in which general practitioners performed
unsuccessful extractions, highlighting the relevance
of not performing surgical interventions without
having a proper expertise on the field. Based on that,
we recommend that third molar extractions should be
preferentially managed by maxillofacial surgeons for
optimal surgical outcomes.
Considering the current literature, most of the third
molars displacements into the sublingual space
allows for a second surgical intervention under local
anesthesia, making feasible a faster postoperative
recovery, as observed in our study. An optimal
postoperative recovery also depends on the technique
addressed during the second approach for third molar
removal. In some situations invasive techniques, such
as double mucoperiosteal flaps, are necessary [16];
while in other cases high-tech performances, such as
endoscopic-assisted retrieval, are feasible [18]. In the
present case a single large mucoperiosteal surgical
flap was necessary to reach the displaced third molar.
Despite a close relation between the third molar and
the submandibular salivary gland and the lingual
nerve, no postoperative sequel was reported by the
patient.
Independent from the situation, the level of surgical
difficulty must be examined in forehand. Specifically,
cases involving tilted and multiradicular third molars,
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Silveira et al.
and in close relation with neurovascular bundles, must
detailed studied for an optimal surgical intervention.
In this context, the radiographic surgical planning
is the most adequate approach to avoid third molar
accidental displacement [19]. Cone-beam and
multislice computed tomography play an important
role, allowing for detailed analysis through three-
dimensional reconstructions and slice navigation. In
combination, the knowledge concerning the anatomy
of head and neck is essential for an adequate and
planned intervention.
In parallel to the surgical care, accidents involving
iatrogenic performances must be promptly reported
to the patient, or legal responsible, informing the
patients health status and treatment choices [20].
Thus, the bioethical principle of autonomy, which
comprehends the patients rights of being informed,
and making decisions, is respected [21]. Above all,
more important is the preoperative description of
technical steps and potential risks, and further record
of the patients decision within a signed informed
consent form [21,22]. Despite the best approach for
clinical solutions involving iatrogenic performances,
the dialogue not always avoids juridical complaints.
In this context, the combination of preoperative
imaging data, surgical plan, technical knowledge,
informed consent, and the correct registration of the
patients files plays a valuable part as the main tool
to support the professional against legal and ethic
complaints.
CONCLUSIONS
Despite common in the routine of maxillofacial
surgeons, the third molar extraction is subject
to transoperative complications. Based on that,
professionals must be aware to the fact of keeping
patients informed prior to the technical procedure,
and supported after the treatment. Additionally, the
present case report highlights the importance of
technically planning and performing oral surgeries;
requesting and interpreting complementary exams;
and registering the patients consent; in face of legal
and ethic potential complaints.
ACKNOWLEDGMENTS AND DISCLOSURE
STATEMENTS
The authors report no conflicts of interest related to
this study.
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REFERENCES

1. Azenha MR, Kato RB, Bueno RB, Neto PJ, Ribeiro MC. Accidents and complications associated to third molar surgeries
performed by dentistry students. Oral Maxillofac Surg. 2013 Dec 27. [Epub ahead of print] [Medline: 24370576]
[doi: 10.1007/s10006-013-0439-9]
2. Shahakbari R, Mortazavi H, Eshghpour M. First report of accidental displacement of mandibular third molar into
infratemporal space. J Oral Maxillofac Surg. 2011 May;69(5):1301-3. Epub 2011 Jan 6. [Medline: 21211881]
[doi: 10.1016/j.joms.2010.06.215]
3. Tumuluri V, Punnia-Moorthy A. Displacement of a mandibular third molar root fragment into the pterygomandibular
space. Aust Dent J. 2002 Mar;47(1):68-71. [Medline: 12035962]
4. Medeiros N, Gaffre G. Accidental displacement of inferior third molar into the lateral pharyngeal space: case report.
J Oral Maxillofac Surg. 2008 Mar;66(3):578-80. [Medline: 18280399] [doi: 10.1016/j.joms.2005.10.042]
5. Huang IY, Wu CW, Worthington P. The displaced lower third molar: a literature review and suggestions for management.
J Oral Maxillofac Surg. 2007 Jun;65(6):1186-90. Review. [Medline: 17517304]
6. Ozyuvaci H, Firat D, Tanyel C. Accidental displacement of a mandibular third molar: a case report. Quintessence Int.
2003 Apr;34(4):278-80. [Medline: 12731614]
7. Aznar-Arasa L, Figueiredo R, Gay-Escoda C. Iatrogenic displacement of lower third molar roots into the
sublingual space: report of 6 cases. J Oral Maxillofac Surg. 2012 Feb;70(2):e107-15. [Medline: 22260911]
[doi: 10.1016/j.joms.2011.09.039]
8. Souza RP, Paes Jr AJO, Volpato R. The sublingual space. Radiol Bras. 2003 Apr;36(1):35-40. Portuguese.
[URL: http://ref.scielo.org/3r53j9] [doi: 10.1590/S0100-39842003000100009]
9. Mendes MB, de Carvalho Leite Leal Nunes CM, de Almeida Lopes MC. Anatomical relationship
of lingual nerve to the region of mandibular third molar. J Oral Maxillofac Res. 2014 Jan 1;4(4):e2.
[URL: http://www.ejomr.org/JOMR/archives/2013/4/e2/v4n4e2ht.htm] [Medline: 24478912] [PMC free article:
3681098] [doi: 10.5037/jomr.2013.4402]
10. Macfarlane TV, Blinkhorn AS, Stevenson LJ, Coulthard P. Third molar removal and orofacial pain: a population-based
survey. J Oral Maxillofac Res. 2010 Oct 1;1(3):e4. [URL: http://www.ejomr.org/JOMR/archives/2010/3/e4/e4ht.htm]
[Medline: 24421974] [PMC free article: 3886054] [doi: 10.5037/jomr.2010.1304]
11. Gmez-Oliveira G, Arribas-Garca I, Alvarez-Flores M, Gregoire-Ferriol J, Martnez-Gimeno C. Delayed removal of a
maxillary third molar from the infratemporal fossa. Med Oral Patol Oral Cir Bucal. 2010 May 1;15(3):e509-11. [Medline:
20038889] [doi: 10.4317/medoral.15.e509]
12. Hoekema A, Apperloo RC, de Lange J. [A rare complication during the surgical removal of an impacted maxillary third
molar]. Ned Tijdschr Tandheelkd. 2012 Jul-Aug;119(7-8):363-6. Dutch. [Medline: 22897034]
13. Huang IY, Chen CM, Chang SW, Yang CF, Chen CH, Chen CM. Surgical management of accidentally displaced
mandibular third molar into the pterygomandibular space: a case report. Kaohsiung J Med Sci. 2007 Jul;23(7):370-4.
[Medline: 17606433] [doi: 10.1016/S1607-551X(09)70424-3]
14. Aznar-Arasa L, Figueiredo R, Gay-Escoda C. Iatrogenic displacement of lower third molar roots into the
sublingual space: report of 6 cases. J Oral Maxillofac Surg. 2012 Feb;70(2):e107-15. [Medline: 22260911]
[doi: 10.1016/j.joms.2011.09.039]
15. Juodzbalys G, Daugela P. Mandibular third molar impaction: review of literature and a proposal of a classification. J
Oral Maxillofac Res. 2013 Jul 1;4(2):e1. Review. [URL: http://www.ejomr.org/JOMR/archives/2013/2/e1/v4n2e1ht.htm]
[Medline: 24422029] [PMC free article: 3886113] [doi: 10.5037/jomr.2013.4201]
16. Pippi R, Perfetti G. Lingual displacement of an entire lower third molar. Report of a case with suggestions for prevention
and management. Minerva Stomatol. 2002 Jun;51(6):263-8. English, Italian. [Medline: 12147979]
17. Olusanya AA, Akadiri OA, Akinmoladun VI. Accidental displacement of mandibular third molar into soft tissue: a case
report. Afr J Med Med Sci. 2008 Mar;37(1):77-80. [Medline: 18756859]
18. Engelke W, Fuentes R, Beltrn V. Endoscopically assisted removal of a lingually displaced third molar adjacent to the inferior
alveolar nerve. J Craniofac Surg. 2013 Nov;24(6):2171-4. [Medline: 24220432] [doi: 10.1097/SCS.0b013e3182a2d834]
19. Agarwal AK, Kanekar SG. Submandibular and sublingual spaces: diagnostic imaging and evaluation. Otolaryngol Clin
North Am. 2012 Dec;45(6):1311-23. Review. [Medline: 23153751] [doi: 10.1016/j.otc.2012.08.005]
20. Nusrath MA, Banks RJ. Unrecognised displacement of mandibular molar root into the submandibular space. Br Dent J.
2010 Sep 25;209(6):279-80. [Medline: 20871549] [doi: 10.1038/sj.bdj.2010.816]
21. Franco A, Alqerban A, Lima AAS, Tanaka OM, Frana BHS. The orthodontists responsibility
and the bioethical aspects in the current jurisprudence. Eur J Gen Dent. 2012 Sep;1(1):20-3.
[URL: http://www.ejgd.org/article.asp?issn=2278-9626;year=2012;volume=1;issue=1;spage=20;epage=23;aulast=Franc
o#ft13] [doi: 10.4103/2278-9626.101350]
22. Yalcin S, Aktas I, Emes Y, Atalay B. Accidental displacement of a high-speed handpiece bur during mandibular
third molar surgery: a case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008 Mar;105(3):e29-31.
[Medline: 18280942] [doi: 10.1016/j.tripleo.2007.09.017]

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To cite this article:

Silveira RJ, Garcia RR, Botelho TL, Franco A, Silva RF. Accidental Displacement of Third Molar into the Sublingual Space:
a Case Report.
J Oral Maxillofac Res 2014;5(3):e5
URL: http://www.ejomr.org/JOMR/archives/2014/3/e5/v5n3e5ht.pdf
doi: 10.5037/jomr.2014.5305

Copyright Silveira RJ, Garcia RR, Botelho TL, Franco A, Silva RF. Published in the JOURNAL OF ORAL &
MAXILLOFACIAL RESEARCH (http://www.ejomr.org), 1 October 2014.

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